Hypothyroi di sm

Causes, Killers, and Life-Saving Treatments
Sarah B. Dubbs, MD
a,
*, Ryan Spangler, MD
b
INTRODUCTION
Hypothyroidism is one of the most frequently encountered endocrinology disorders.
Although most of the time this disease does not require immediate emergency evalu-
ation and treatment, the emergency department is often the first point of care for many
patients. This truth makes it essential that emergency physicians have an understand-
ing of basic thyroid function, pathophysiology of thyroid-related disorders, and treat-
ment methodology.
The overarching disease of hypothyroidism can have multiple causes and several
presentations (thus its reputation as a mimicker), but treatment is rather straightfor-
ward. The mainstay of treatment is thyroid hormone supplementation. Outpatient
follow-up and treatment are necessary for complete and accurate treatment of these
patients, but early intervention and referral from the emergency department can be
easy to initiate, and in some severe cases lifesaving.
Myxedema coma, otherwise known simply as myxedema, is the rare but deadly
manifestation of severe hypothyroidism. The extremely high mortality rate (historically
as high as 80%, but still up to 60%) associated with myxedema makes it necessary
for early recognition and treatment by emergency physicians.
1
Although it is not
commonly encountered, a healthy degree of suspicion of the “worst first” mentality
must be maintained to prevent poor outcomes in these patients.
a
Department of Emergency Medicine, University of Maryland School of Medicine, 110 South
Paca Street, 6th Floor Suite 200, Baltimore, MD 21201, USA;
b
Emergency Medicine Residency
Program, University of Maryland Medical Center, 110 South Paca Street, 6th Floor Suite 200,
Baltimore, MD 21201, USA
* Corresponding author.
E-mail address: sdubbs@umem.org
KEYWORDS

Thyroid

Hypothyroidism

Myxedema

Levothyroxine

Thyroid-stimulating hormone

Coma
KEY POINTS
Iodine deficiency is the most common cause of hypothyroidism worldwide.
Hashimoto thryoiditis is the most common cause in the United States.
Hypothyroidism is more common in elderly, white women.
Emerg Med Clin N Am 32 (2014) 303–317
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In a study by Chen and colleagues
2
it was noted that in a series of patients admitted
to the hospital with overt hypothyroidism only 21% was diagnosed on admission.
Perhaps more concerning was that 50% of patients in the study ultimately diagnosed
with myxedema went undiagnosed. This study indicates that hypothyroid crisis is not
well recognized by emergency physicians. In fact, it can be argued that the main job of
the emergency physician is to identify thyroid disorders whenever possible. Higher-
risk populations include elderly patients and those with cardiovascular and neuropsy-
chiatric illness because thyroid function can be closely tied to these entities.
EPIDEMIOLOGY
In the developed world, thyroid disease is often found to be associated with autoim-
mune disease and is approximately 5 to 10 times more common in women than in
men.
3,4
In Europe, studies have shown that the incidence of hypothyroidism may
also be increasing, although it is unclear if this is fromincreased awareness or an over-
all increase in autoimmune disorders.
3
The National Health and Nutrition Examination
Survey III found subclinical hypothyroidism to be present in 4.3% and overt hypothy-
roidism in 0.3% of the US population. Other studies indicate that up to 15% of older
women may have subclinical hypothyroidism. Higher thyroid-stimulating hormone
(TSH) and antithyroid antibodies are found in women, the elderly, whites, and Mexi-
cans (compared with African Americans).
5
A trend has also been found in increased
prevalence of autoimmune disorders and subsequently hypothyroidism.
3
Much of
these studies focused on chart review and treatment of hypothyroidism, suggesting
that an even higher number of subclinical and unidentified patients may be present.
Hypothyroidism can be classified into three categories: (1) primary (thyroid gland),
(2) secondary (pituitary gland), or (3) tertiary (hypothalamus). Causes of primary hypo-
thyroidismvary by location, but it is the most common type of hypothyroidism.
4
World-
wide, iodine deficiency is the most common cause. However, in the United States and
other iodine-replete areas, chronic thyroiditis, also known as Hashimoto thyroiditis, is
the most common cause.
6
Central hypothyroidism has even lower rates, and is
thought to be approximately 1 in every 1000 cases of hypothyroidism, most frequently
caused by pituitary adenoma.
7
It is a common side effect of treatment of several other
conditions and can be seen in 20% to 50% of patients irradiated for nasopharyngeal
and paranasal sinus tumors. However, the affects tend to show up several years later
rather than immediately.
4,7
Sheehan syndrome and traumatic brain injury can also
cause central hypothyroidismthrough direct or indirect mechanisms. Table 1 summa-
rizes the types and etiologies of hypothyroidism.
PATHOPHYSIOLOGY
Overall, the production and regulation of thyroid hormones is a relatively simple feed-
back system. The biochemical synthesis at a cellular and molecular level is somewhat
more complex and not as immediately relevant to an emergency physician’s goals.
The process begins in the hypothalamus with the production of thyrotropin-
releasing hormone (TRH). TRH then stimulates the anterior pituitary to secrete
TSH.
8
After TSH is released, this stimulates the thyroid to release synthesize, and
secrete trioiodothryonine (T3) and thyroxine (T4) from the thyroid itself. T3 and T4
both feed back to the hypothalamus and the pituitary to inhibit TRH and TSH. This
feedback mechanism allows for very tight control of TSH levels in the serum.
9,10
Fig. 1 shows the relationships between the hormones.
Centrally, TRH and TSH are secreted according to a circadian rhythm, with a
nocturnal surge in the early nighttime hours. This can be affected by derangements
Dubbs & Spangler 304
in gonadal hormones, leptin, and other feeding- and sleep-related hormones, which
can affect hypothalamic-pituitary feedback. This results in the condition of central
hypothyroidism, which can be difficult to detect, because TSH can be normal, or
even slightly elevated in some patients. This is because it is not always a matter of
decreased quantity, but also secretion of dysfunctional TSH.
4
Most T4 produced is stored in the bloodstream and body attached to thyroxine-
binding globulin (TBG), albumin, transthyretin (prealbumin), and other lipoproteins.
While attached to these molecules, the T4 is not biochemically active but provides
Table 1
Causes of hypothyroidism
Primary (thyroid gland dysfunction) Iodine deficiency
Autoimmune thyroiditis
Hashimoto thyroiditis
Atrophic autoimmune thyroiditis
Medication-induced (see Table 2)
Congenital hypothyroidism
Thyroid aplasia or hypoplasia
Defective synthesis of thyroid hormones
Iatrogenic
Thyroidectomy
Cancer treatments
Central
Secondary (pituitary dysfunction)/tertiary
(hypothalamic dysfunction)
Pituitary adenoma
Craniopharyngioma
Traumatic brain injury
Sheehan syndrome
Iron overload
Sarcoidosis
Syphilis
Tuberculosis
Data from Vaidya B, Pearce S. Management of hypothyroidism in adults. BMJ 2008;337:a801; and
Persani L. Central hypothyroidism: pathogenic, diagnostic and therapeutic challenges. J Clin Endo-
crinol Metab 2012;97(9):3068–78; with permission.
Fig. 1. Thyroid feedback loop.
Hypothyroidism 305
a reservoir of stored T4, capable of maintaining function for days even if thyroid func-
tion were to cease. The protein binding further provides buffer against overactivity of
thyroid hormones.
11
Although T3 is also produced in the thyroid, only a small percentage of T3 is actually
made in the thyroid itself. About 80% is produced in extrathyroidal tissues by deiodi-
nation of T4. The primary sites of conversion occur in the liver and the kidneys, but
most tissues are capable of performing this. T3 is also bound by TBG, albumin, and
transthyretnin, ready for immediate use and storage as needed.
11
When T4 is released and peripherally converted into the bioactive T3, the overall
effect is to increase metabolism. There is a direct action of increased peripheral oxy-
gen consumption and thermogenesis. Also, T3 has direct cardiovascular effects to
increase ionotropy and chronotropy. Increased cardiac output is somewhat of an
indirect result. In hypothyroidism, the end result is the opposite. The exaggerated re-
sponses of hypothermia, bradycardia, and hypotension seen in myxedema are an
example of this.
1
Primary hypothyroidism, as seen in Hashimoto thyroiditis, is the result of cell and
antibody-mediated destruction of thyroid tissue. Antibodies to thyroperoxidase, thyro-
globulin, TSH receptors, and TSH blocking antibodies can all contribute. Because the
thyroid needs iodine to build T4 and T3, iodine deficiency causes thyroid deficiency. A
transient hypothyroidism can be seen with iodine excess, and is known as Wolff-
Chaikoff effect. Frequently, medications can cause hypothyroidism. Frequently cited
medications are amiodarone and lithium, with incidence of hypothyroidism of
14% to 18% and 10%, respectively. Overuse of antihyperthyroid medications propo-
thiouracil and methimazole can lead to hypothyroidism. Other common causes are
thyroidectomy or radioactive iodine treatment (see Table 1; Table 2).
7
EMERGENCY DEPARTMENT PRESENTATION
The hypothyroid patient most frequently presents to the emergency department with
multiple, vague complaints of insidious onset, and has a nonspecific physical exami-
nation. These circumstances can make the diagnosis elusive even to the attentive
physician. The presenting symptoms and signs often vary with age and gender, and
the severity of these clinical features varies greatly. Despite the difficulty of diagnosis,
routine screening is not recommended in the emergency department because of the
effects of nonthryoidal illnesses on thyroid function tests, and national guidelines vary
on how best to approach screening in the United States.
4,12
CLINICAL FEATURES
The hypothyroid state’s multitude of manifestations is a result of every organ system
relying on thyroid hormone for normal function. The insufficient level of the hormone
causes a spectrum of depression in the function of these systems. See Table 3 for
Table 2
Medication effects on native thyroid function
Decreased TSH secretion Dopamine, glucocorticoids, octreotide,
metformin, opiates
Decreased thyroid hormone secretion Lithium, iodine/iodinated contrast, amiodarone
Increased thyroid hormone metabolism Phenobarbital, rifampin, phenytoin,
carbamazepine
Dubbs & Spangler 306
a summary of the signs and symptoms of hypothyroidism. Box 1 lists some examples
of common presentations of hypothyroidism. The most extreme end of this spectrum
is myxedema coma. Although it is rare, myxedema coma is life-threatening and must
be recognized and treated emergently.
Symptoms
Symptoms of progressive fatigue and malaise are almost always present with hypo-
thyroidism. Weight gain is another frequent and typical symptom, caused by
decreased metabolic rate and oxygen consumption.
4
Other common symptoms
include cold intolerance, voice changes, dry skin, hair loss, constipation, irregular
menses, difficulty concentrating, memory problems, and depression. Patients also
report myalgias, arthralgias, and paresthesias. Some may even present with sexual
dysfunction or impaired fertility. A child may manifest hypothyroidism with impaired
growth or delayed puberty.
Table 3
Clinical features of hypothyroidism
Symptoms Signs
Fatigue
Weight gain
Cold intolerance
Hoarse voice
Dry skin and hair
Constipation
Irregular menses and/or menorrhagia
Sexual dysfunction
Impaired fertility
Difficulty with concentration
Myalgias and arthralgias
Paresthesias
Memory deficits
Depression
Goiter
Nonpitting edema
Coarse, dry skin and hair
Brittle nails
Macroglossia
Slowed relaxation phase of reflexes
Psychosis
Bruising/bleeding
Pericardial or pleural effusion
Ascites
Hypothermia
Hypotension
Hypoglycemia
Altered mental status/coma
Signs of myxedema coma are shown in boldface.
Box 1
Common patient presentations associated with hypothyroidism
Elderly patients
With new psychiatric complaints
With cramping, constipation
Patient with combination of weakness, weight gain, and/or hyponatremia
History of depression, weight gain, hoarseness
Young “anemic” woman with frequent episodes of heavy vaginal bleeding
Patient with history of hypertension who develop sudden hypotensive episodes, even after
reduction of medication
Refractory hypotension not responsive to routine treatments
Adapted from Tews MC, Shah SM, Gossain VV. Hypothyroidism: mimicker of common com-
plaints. Emerg Med Clin North Am 2005;23:654; with permission.
Hypothyroidism 307
Physical Examination Findings and Signs
Head and neck
The hypothyroid patient presents with coarse facial features, dry skin, and pallor. His
or her hair may be coarse as well, with visible thinning. Facial edema, especially peri-
orbital, can be caused by hypothyroidism. Some patients have macroglossia, which
can affect their speech, in addition to a hoarse, deep voice. Finally, goiter, if present,
is a fairly obvious and sensitive sign of thyroid dysfunction.
Cardiovascular
Vital signs reveal bradycardia, diastolic hypertension, and in severe cases hypoten-
sion as a result of depressed cardiac output. Diastolic hypertension is attributable
to increased systemic vascular resistance. Overall cardiac output is decreased, sec-
ondary to the slower heart rate and decreased contractility.
13,14
Signs of pericardial effusion, such as muffled heart sounds, rubs, and jugular venous
distention, pulsusparadoxis may be present on physical examination. Bedside ultra-
sound examination quickly confirms the presence or absence of effusion and tampo-
nade physiology.
Respiratory
Breath sounds may be decreased or abnormal because of hypoventilation and/or
pleural effusions.
Abdominal
As with the cardiovascular and respiratory examinations, the abdominal examination
may reveal effusion in the form of ascites. Abdominal ascites is relatively rare, occur-
ring in approximately 4% of patients with thyroid disease.
15
Hypothyroidism may also
cause constipation and ileus. Thus, bowel sounds may be hypoactive on auscultation
and the patient may have mild, diffuse tenderness on palpation.
Dermatologic
Hypothyroid patients have fluffy, nonpitting edema, also known as myxedema.
Myxedema derives from the Greek word for mucous, describing the glycosaminogly-
cans deposition that causes this distinctive edema.
16
The skin may also take on a pallor appearance caused by hypothyroid-induced ane-
mia. The skin is dry and coarse, nails brittle as well, and hair is coarse with areas of
alopecia. There have been some reports of psoriasiform lesions related to severe
hypothyroidism.
17
Neurologic
Many of the neurologic findings associated with hypothyroidism center around cogni-
tive functions, such as orientation, memory, and higher-order thinking.
Patients may also display muscle hypertrophy, proximal muscle weakness, and
easy fatigability of strength.
18
Nerve entrapment syndromes, such as carpel tunnel
syndrome, can occur as a result of edema. This finding is revealed on examination
when pain and paresthesias are reproduced with maneuvers, such as with the Tinel
test and Phalen sign.
19
A delayed relaxation phase in deep tendon reflexes (also
known as the myxedema reflex or Woltman sign) has also been reported frequently
in the literature.
20,21
Psychiatric
Hypothyroid patients may suffer from depression, reflecting in the physical examina-
tion as a slow, flat affect. Some may even display signs of psychosis by responding
to internal stimuli or expressing delusional thoughts, a state often referred to as
Dubbs & Spangler 308
“myxedema madness.” In general, laboratory evaluation in psychiatric patients is
guided by the history and physical examination. However, with the possibility of sub-
clinical hypothyroidism and the subtlety of symptoms, a screening TSH should be
considered in this patient population. See Box 1 for several examples of clinical sce-
narios that should trigger a hypothyroidism work-up.
LABORATORY FINDINGS
Diagnosis of Hypothyroidism
This difficulty in diagnosing hypothyroidismdoes not lie in the laboratory studies them-
selves; it lies in the shrewdness of the physician to include it on the list of differential
diagnoses despite the vague and nebulous symptoms and signs with which patients
present.
The first-line diagnostic tool to diagnose hypothyroidism in the emergency depart-
ment is serum thyrotropin testing. Most facilities are able to perform an ultrasensitive
monoclonal antibody test for TSH. These have been shown to be quick, reliable, and
reproducible.
22
An abnormal TSH should lead to further testing of the active thyroid
hormones T4 and T3. Free thyroxine levels can be measure in two ways. Total
thyroxine refers to the combined amount of protein-bound and nonbound hormone.
The free T4 level (FT4) refers only to the unbound form, and as the metabolically active
moiety
23
is preferred over the total thyroxine level.
12
High TSH
An elevated TSH indicates some level of hypothyroidism, determined by the level of
circulating T4 and T3. When the FT4 level is low, the disease process is classified
as primary hypothyroidism.
When the FT4 and T3 levels are normal in the setting of lowTSH, the disease is clas-
sified as subclinical hypothyroidism. Subclinical hypothyroidism has multiple etiol-
ogies. It can stem from an incomplete autoimmune process that will eventually lead
to total thyroid failure. Inadequate dosing or absorption in patients who are on
thyroxine replacement medications may also be the cause of these abnormal labora-
tory values; however, it must be noted that the TSH can be persistently elevated for up
to 6 weeks after initiating thyroxine therapy.
24,25
Other times, it can be part of the
normal recovery phase in nonthyroidal illness as the body tries to compensate for
low thyroid hormone synthesis during the illness. Finally, the TSH can be elevated
with normal T4 and T3 levels during acute psychiatric illness and with abuse of
amphetamines.
26
Elevated TSH with elevated FT4 and T3 points to a primary TSH problem, usually a
TSH-secreting adenoma in the pituitary gland causing hyperthyroidism.
Normal TSH
A normal TSH level is a fairly reliable indicator of normal thyroid function. Therefore,
other nonthyroidal etiologies must be investigated for the patient’s symptoms when
TSH levels are normal. In the rare case of central hypothyroidism, TSH levels can be
inappropriately normal, accompanied by low levels of T4.
26
Low TSH
Low TSH is almost always associated with hyperthyroidism. In the setting of hypothy-
roid symptoms, an abnormally low level of TSH can result from overall reduced TSH
production, called secondary hypothyroidism. In patients who are on thyroxine therapy
for hypothyroidism, it can be caused by a dose that is too high. Finally, certain
Hypothyroidism 309
medications, such as dopamine and corticosteroids, have been shown to depress
TSH levels.
27
Associated Laboratory Findings
The global effects of thyroid dysfunction cause a wide variety of other laboratory ab-
normalities in hypothyroid patients. Anemia is frequently encountered in association
with hypothyroidism. Depressed red blood cell production causes a normochromic,
normocytic anemia. If significant menorrhagia is playing a role, the patient may display
an iron-deficiency anemia with a hypochromic, microcytic picture. Many hypothyroid
patients also have an autoimmune-related pernicious anemia, resulting in a macro-
cytic anemia.
Severely hypothyroid patients may also develop coagulopathy, with abnormal clot-
ting times and international normalized ratio. Platelet counts may be normal despite
abnormal function.
Renal free water secretion is reduced in hypothyroidism, causing hyponatremia.
28,29
Renal insufficiency is also present in severe hypothyroidism, reflected in elevated
brain urea natriuretic peptide and creatinine levels.
Decreased gluconeogenesis and reduced insulin clearance leads to hypoglycemia.
This process may be solely caused by the hypothyroid state; however, it may be attrib-
uted to a more serious process, adrenal insufficiency. Hypoglycemia (and the concur-
rent hypotension and other symptoms and signs) related to adrenal insufficiency must
be identified as such to be treated appropriately.
Increased muscle membrane permeability allows muscle enzymes to leak into the
serum. Creatine kinase levels are elevated to reflect this process.
Decreased respiratory drive is reflected on an arterial blood gas analysis as hyper-
capnia and hypoxemia with respiratory acidosis.
Other abnormal laboratory values associated with hypothyroidism are elevated
transaminases, lactate, and cholesterol. When lumbar puncture is performed as part
of the diagnostic process, elevated opening pressure and cerebrospinal fluid protein
levels can be present with profound hypothyroidism.
30
TREATMENT
Hypothyroidism
Although there are many causes of hypothyroidism, the main goal of treatment is to
replace the thyroid hormones that are lacking, T3 and T4. Generally, this involves a
synthetic compound levothyroxine. Levothyroxine is identical to T4, and is converted
to T3 in extrathyroidal tissue the same way endogenously produced T4 is converted.
Levothyroxine has a half-life of 7 days so it reaches a steady state rapidly when
started on 1.6 mg/kg/day dosing as recommended. Special note should be taken
for patients older than age 60 and those with ischemic cardiovascular disease, and
should start at a lower dose. There is some discussion of combination therapy with
T4 and T3, but there has been no demonstrated benefit over simple levothyroxine
therapy.
6
This one medication approach seems very simple and straightforward; how-
ever, different brand preparations of this medication tend to vary slightly in available
drug concentrations and switching manufacturers can result in inadequate or over-
treatment based on prior regimens. In addition, in one study 40% to 48% of patients
on levothyroxine were either overtreated or undertreated.
6
For patients with a
known history of hypothyroidism presenting with worsening symptoms, a thorough
medication history should be obtained for possible recent pharmacy changes.
23,31
Dubbs & Spangler 310
The American Association of Clinical Endocrinologists suggests a mean dose of
1.6 mg/kg of ideal body weight.
23
However, each individual may be different depending
on the degree of thyroid dysfunction, concurrent medications, and general respon-
siveness. Titration of medication is based on normalization of TSH levels, and should
be first analyzed at approximately 6 weeks, with slow titration of 12.5 to 25 mg adjust-
ments and repeat TSH every 1 to 2 weeks.
23
Obviously 6-week follow-up in the emer-
gency department is not a feasible plan for continued care, but it may be important to
take into account for patients recently started on levothyroxine with possible over-
treatment or undertreatment.
Patients starting levothyroxine or being prescribed new medications need to be
aware of possible drug interactions and their effect on levothyroxine dosing. Many
drugs can affect levothyroxine at various aspects of its therapeutic course. Common
drugs, such as aluminum hydroxide, ferrous sulfate, and calcium, can potentially
affect absorption of levothyroxine in the gastrointestinal tract. Other drugs, such as
rifampin and sertraline, can affect metabolismand require a higher dosing. Anticonvul-
sants, birth control pills, and other protein-bound medications can affect the binding
of levothyroxine to TBG, albumin, and other proteins that can alter the amount of
active drug in the bloodstream.
23
Table 4 summarizes the effects that some common
medications have on levothyroxine.
Subclinical Hypothyroidism
Although in the emergency department it is rare to order screening tests, the chance of
identifying subclinical hypothyroidism may still occur (elevated TSH, normal T3/T4).
Treatment of subclinical hypothyroidism is controversial, because with normal
T4 levels there are generally no symptoms as this is the bioactive compound. The
American Association of Clinical Endocrinologists recommends treatment of TSH
levels greater than 10, with presence of goiter, or antithyroid peroxidase antibodies
because these patients have been shown to be the most likely to progress to true hy-
pothyroidism. It is recommended that a lower dose be used to treat subclinical levels,
starting at 35 to 50 mg daily, with standard follow-up.
23
Pregnancy
Treatment of hypothyroidism in pregnant patients is of particular importance, and TSH
screening is recommended as a routine prepregnancy and prenatal work-up. In preg-
nancy some women may develop thyroid antibodies that can increase the chance for
spontaneous abortion regardless of treatment. Untreated hypothyroidism, even mild,
in pregnant women increases the risk of several complications including preeclamp-
sia, anemia, postpartum hemorrhage, fetal death, low birth weight, and others.
Studies do suggest that cognitive dysfunction of offspring can be prevented with treat-
ment. Levothyroxine is pregnancy class A (also safe in lactation) and it is recommen-
ded to initiate, or continue appropriate treatment in pregnant patients. It is also
important to note that in general the course of a patients hypothyroidism during preg-
nancy is unpredictable. In those with chronic hypothyroidism, some improve their
symptoms and some get worse.
32
DISPOSITION
In general, the disposition status of the hypothyroid patient presenting to the emer-
gency department is straightforward. Many of these patients can be discharged
home, with the caveat that follow-up is required, particularly if long-term levothyroxine
therapy has been started. The recommended follow-up window is 6 weeks after
Hypothyroidism 311
initiation to reevaluate TSH levels. Some patients exhibiting severe hypothyroidism
may require admission to the hospital if it is believed by the physician that the patient
is unsafe to be discharged home to reliably follow-up and take medication. If the
patient’s disease is thought to be medication-induced, the risks and benefits of
continuing or discontinuing the offending medication must be carefully considered.
As always, the patient’s mental status and psychological status is an important factor
in the disposition decision.
MYXEDEMA COMA
Myxedema coma, or simply myxedema, is the most severe manifestation of hypothy-
roidismwith a mortality rate of 30%to 60%, a decrease fromalmost 80%in the past.
33
Its incidence is rare, and exact numbers are not known based on difficulty of specific
Table 4
Drug effects on levothyroxine treatment
Mechanism of Effect Agents
Interference with absorption Bile acid sequestrants
Sucralafate
Cationexchance resins (Kayexelate)
Oral bisphosphonates
Proton pump inhibitors
Raloxifene
Ferrous sulfate
Phosphate binders
Calcium
Chromium picolinate
Charcoal
Orlistat
Ciprofloxacin
H
2
receptor antagonists
Grapefruit juice, espresso coffee, high fiber, soy products
Increased clearance Phenobarbitol
Primidone
Phenytoin
Carbamazepine
Oxacarbazepine
Rifampin
Growth hormone
Sertraline
Tyrosine kinase inhibitors
Quetiapine
Stavudine
Nevirapine
Peripheral metabolism Glucocorticoids
Amiodarone
Propylthiouracil
b-Blockers
Iodinated contrast
Interleukin-6
Clomipramine
Agents that are frequently used in the emergency department are shown in boldface.
Data from Garber J, Cobin R, Gharib H, et al. Clinical practice guidelines for hypothyroidism in
adults: cosponsored by the American Association of Clinical Endocrinologists and the American
Thyroid Association. Endocr Pract 2012;18(6):1004.
Dubbs & Spangler 312
definition and possible underrecognition. A frequently cited contributory clue is
change in weather, with up to 90% of cases occurring during winter months. It is theo-
rized that this is caused by altered temperature regulation in the severely hypothyroid
patient. Myxedema coma is more common among older women and almost never oc-
curs in individuals younger than age 60. Also, there are little data on incidence of
myxedema in the equatorial regions, which may be the result of underreporting, but
it is hypothesized that the lack of seasonality may play a role.
34,35
The cardinal signs of myxedema coma are depressed mental status and hypother-
mia. If a history is available, the patient or family may report the signs and symptoms of
undiagnosed hypothyroidism, as described previously; or, the patient may even
already carry the diagnosis. The cardiovascular, respiratory, gastrointestinal, renal,
and hematologic manifestations of hypothyroidism are at the severe end of the spec-
trum. Severe hypotension and shock may be the result of depressed cardiac contrac-
tility, tamponade, or bradydysrhythmias. Myxedema has even been reported to cause
prolongation of the Q-T interval, predisposing patients to torsades de pointes.
36
Hypo-
ventilation can be so profound that acid-base status is disturbed. Patients may have
associated gastrointestinal bleeding caused by myxedema-associated coagulop-
athy.
37
The physical findings associated with myxedema coma are, again, on the
extreme end of the hypothyroid symptoms described previously: dough-like nonpit-
ting edema, dry and brittle skin and hair, delayed reflexes, and of course altered sen-
sorium. Some of the most common precipitating events of myxedema coma are listed
in Box 2.
Laboratory testing should not only focus on diagnosing the hypothyroidism with
TSH and thyroxine levels; it should include investigation into the wide differential of
altered mental status. Furthermore, a wide net should be cast to identify possible
precipitating and aggravating factors in the myxedema state. Common precipitators
of myxedema coma are infections, strokes, congestive heart failure, exposure to
low ambient temperature, trauma, gastrointestinal bleeding, and metabolic distur-
bances. Medications, such as anesthetics, sedatives, narcotics, amiodarone, lithium,
and changes to levothyroxine-replacement therapy, are also known to precipitate
myxedema coma.
38
Treatment of patients with myxedema coma can vary among practitioners and there
is not a consistent or proved method of treatment. Largely because of the rarity of the
Box 2
Precipitating events causing myxedema coma
Infection or sepsis
Gastrointestinal hemorrhage
Hypoglycemia
Hypothermia
CO
2
retention
Burns or trauma
Medications
Stroke
Data from Klubo-Gwiezdzinska J, Wartofsky L. Thyroid emergencies. Med Clin North Am
2012;96(2):385–403; and Wall CR. Myxedema coma: diagnosis and treatment. AmFamPhysician
2000;62(11):2485–90.
Hypothyroidism 313
illness, there are no large studies, and certainly no randomized controlled trials inves-
tigating this treatment. Controversy exists in treatment with T4 versus T3, intravenous
(IV) versus oral based on bioavailability of each drug.
39
However, there is some litera-
ture present noting that using T3 can result in increased mortality, although the cause
is not clear and most studies are small case reports. Most sources, because of this,
recommend treatment of IV or oral levothyroxine, because evidence does not seem
to indicate significant difference between the two.
1
General recommendations suggest the use of 100 to 500 mg of IV levothyroxine.
Dosing tends to vary based on different studies, some recommending lower dosing
for older, frailer patients, especially those with cardiovascular disease. Other sources
recommend a size-base dosing calculating total body distribution of levothyroxine and
administering a distribution size dose of 6 mg/dL (70-kg man, 7-L distribution area,
420-mg dose of levothyroxine). This initial loading dose should be followed by 50 to
100 mg of IV levothyroxine daily until the patient is able to be converted to an oral
formulation.
40
Those in favor of using T3 suggest a loading dose of 10 to 20 mg followed by 10 mg
every 4 hours for 24 hours, then 10 mg every 6 hours for 1 to 2 days until the patient can
continue with oral medication. An eight-patient case series by Yamamoto and co-
workers
41
suggests that although dosing ranges are large, overdosing should be
avoided because doses of levothyroxine greater than 500 mg and T3 greater than
75 mg were both associated with increased mortality. Combination therapy of levothyr-
oxine and T3 may be useful, with a loading dose of 4 mg/kg ideal body weight of
levothyroxine, followed by 100 mg in 24 hours, then 50 mg daily, IV or orally. T3 would
be started simultaneously with doses of 10 mg every 8 to 12 hours until the patient can
take oral maintenance doses of levothyroxine.
41
Although the initial loading dose and exact medication to be used for thyroid
replacement is not well established, the use of IV hydrocortisone is consistently rec-
ommended throughout the literature. Because of the potential of secondary hypothy-
roidism and concurrent hypopituitarism, there is strong potential for associated
adrenal insufficiency. A dose of 100 mg every 8 hours IV hydrocortisone is suggested
to be continued until adrenal insufficiency is ruled out. Some sources suggest a
random cortisol level be drawn before treatment to assess adrenal function, and if
necessary a corticotropin stimulation test can be performed later. Most recommend
discontinuing the hydrocortisone without taper needed once adrenal insufficiency is
ruled out.
33
Further treatment of myxedema coma is necessary to treat the precipitating cause.
This can be environmental, infectious, medication induced, or otherwise. Many rec-
ommendations suggest immediate septic work-up up including broad-spectrum anti-
biotics after cultures have been sent. Lumbar puncture is also likely to be necessary in
these patients to rule out meningitis as a cause of altered mental status and hypother-
mia. Special thought needs to be given to finding the precipitating event because this
in and of itself can potentially be life threatening.
Critical care treatment of patients with myxedema coma is often necessary because
of the severity of illness. Intubation in these patients may be necessary, and has the
potential of being a difficult procedure. Patients with hypothyroidism can often be
overweight, coupled with the potential for airway myxedema, making airway manage-
ment difficult. The patients may also have already developed hypercapnia caused by
hypoventilatory effects of their illness, have reduced lung volumes, and in severe
cases, pleural and pericardial effusions, which can lead to cardiovascular and respi-
ratory collapse if not managed appropriately.
42
Furthermore, external airway anatomy,
such as a large goiter, may cause tracheal deviation, and certainly obstruct normal
Dubbs & Spangler 314
cervical anatomy needed to easily perform an emergent cricothyrotomy if necessary.
These recommendations are summarized in Box 3.
Patients with suspected myxedema coma by definition have altered mental status
and should always be admitted to the hospital with strong consideration for an inten-
sive care unit level admission. These patients can present very sick because their
inherent compensatory mechanisms are dysfunctional due to the severe hypothyroid
state. In addition, the precipitating factor for their myxedema can be severe, such as
sepsis, myocardial infarction, or stroke. Mortality for myxedema tends to increase in
hypothermic patients based on the severity of their hypothermia.
43
A study by Dutta
and colleagues
44
also noted that patients that were noncompliant with previously pre-
scribed thyroid-replacement medication tended to have higher mortality than those
with first-time diagnoses. This study also found that an elevated sequential organ fail-
ure assessment (SOFA) score was shown to predict higher mortality.
44
SUMMARY
Hypothyroidism, one of the most common endocrine disorders encountered, is likely
to be directly or indirectly related to frequent patient visits to primary care physicians
Box 3
Summary of recommendations for patients with suspected myxedema coma
Interventions
Airway control
Fluid resuscitation
Diagnostics
Complete blood count
Basic metabolic panel
TSH and free T4 levels
Blood/urine/sputum cultures
Lumbar puncture
Electrocardiogram
Chest radiograph
Head computed tomography
Echocardiogram
Medications
Levothyroxine, 100–500 mg IV loading; then 50–100 mg IV daily (until patient can take oral
medication)
or
Triiodiodothyronine, 10–20 mg loading; then 10 mg q 4 hours for 24 hours, then 10 mg q 6
hours for 1–2 days until the patient can take oral medication
and
Hydrocortisone, 100 mg IV q 8 hours
Broad-spectrum antibiotics
Vasopressors as needed
Hypothyroidism 315
and emergency physicians. The clinical signs and symptoms can be broad, nonspe-
cific, and subtle at times. Myxedema coma can be equally ambiguous but much more
deadly. Early suspicion, recognition, and treatment can improve patient outcomes for
any range of the hypothyroid disorders.
REFERENCES
1. Mills L, Lim S. Identifying and treating thyroid storm and myxedema coma in the
emergency department. Emerg Med Pract 2009;11(8):1–26.
2. Chen T, Hou S, How C, et al. Diagnosis of unrecognized primary overt hypothy-
roidism in the ED. Am J Emerg Med 2010;28:866–70.
3. Flynn RW, MacDonald TM, Morris AD, et al. The thyroid epidemiology, audit, and
research study: thyroid dysfunction in the general population. J Clin Endocrinol
Metab 2004;89(8):3879–84.
4. Devdhar M, Ousman Y, Burman K. Hypothyroidism. Endocrinol Metab Clin North
Am 2007;36:595–615.
5. Hollowell J, Staehling N, Flanders W, et al. Serum TSH, T4, and thyroid antibodies
in the United States Population (1988 to 1994): National Health and Nutrition
Examination Survey (NHANES III). J Clin Endocrinol Metab 2002;87(2):489–99.
6. Vaidya B, Pearce S. Management of hypothyroidism in adults. BMJ 2008;337:
a801.
7. Persani L. Central hypothyroidism: pathogenic, diagnostic and therapeutic chal-
lenges. J Clin Endocrinol Metab 2012;97(9):3068–78.
8. Magner JA. Thyroid-stimulating hormone: biosynthesis, cell biology, and bioac-
tivity. Endocr Rev 1990;11:354.
9. Shupnik MA, Ridgway EC, Chin WW. Molecular biology of thyrotropin. Endocr
Rev 1989;10:459.
10. Dyess EM, Segerson TP, Liposits Z, et al. Triiodothyronine exerts direct cell-
specific regulation of thyrotropin-releasing hormone gene expression in the hypo-
thalamic paraventricular nucleus. Endocrinology 1988;123:2291.
11. Mendel CM, Weisiger RA, Jones AL, et al. Thyroid hormone-binding proteins in
plasma facilitate uniform distribution of thyroxine within tissues: a perfused rat
liver study. Endocrinology 1987;120:1742.
12. Garber J, Cobin R, Woeber K, et al. Clinical practice guidelines for hypothyroid-
ism in adults: cosponsored by the American Association of Clinical Endocrinolo-
gists and the American Thyroid Association. Endocr Pract 2012;18(6):989–1028.
13. Klein I, Ojamaa K. Thyroid hormone and the cardiovascular system. N Engl J Med
2001;344(7):501–9.
14. Coceani M. Heart disease in patients with thyroid dysfunction: hyperthyroidism,
hypothyroidism and beyond [English]. Anadolu Kardiyol Derg 2013;12(1):62–6.
15. Krishnan S, Philipose Z, Rayman G. Lesson of the week: hypothyroidism
mimicking intra-abdominal malignancy. BMJ 2002;325(7370):946.
16. Smith TJ, Bahn RS, Gorman C. Connective tissue, glycosaminoglycans, and dis-
eases of the thyroid. Endocr Rev 1989;10:366–92.
17. Kwinter J, Weinstein M, Bargman H. Psoriasiform lesions and abscesses as initial
manifestations of severe hypothyroidism in a previously healthy 15-year old girl.
Pediatr Dermatol 2007;24(3):321–3.
18. CruzMW, TendrichM, VaismanM, et al. Electroneuromyographyandneuromuscular
findings in 16 primary hypothyroidism patients. Arq Neuropsiquiatr 1996;54:12–8.
19. Sabeen A, Allan G. Musculoskeletal manifestations of thyroid disease. Rheum Dis
Clin North Am 2010;36:637–46.
Dubbs & Spangler 316
20. Houston C. The diagnostic importance of the myxœdema reflex (Woltman’s sign).
Can Med Assoc J 1958;78(2):108.
21. Burkholder D, Klaas J, Kumar N, et al. The origin of Woltman’s sign of myxoe-
dema. J Clin Neurosci 2013;20(9):1204–6.
22. Mirapurkar S, Samuel G, Sivaprasad N. Development of an immunoenzymomet-
ric assay (IEMA) for the estimation of human thyroid stimulating hormone (hTSH)
in serum. J Immunoassay Immunochem 2010;31(4):290–300.
23. Mendel CM. The free hormone hypothesis: a physiologically based mathematical
model. Endocr Rev 1989;10:232–74.
24. Smith SA. Commonly asked questions about thyroid function. Mayo Clin Proc
1995;70:573–7.
25. Khandelwal D, Tandon N. Overt and subclinical hypothyroidism. Drugs 2012;
72(1):17–33.
26. Dayan CM. Interpretation of thyroid function tests. Lancet 2001;357:619–24.
27. Surks MI, Sievert R. Drugs and thyroid function. N Engl J Med 1995;333(25):
1688–94.
28. DeRubertis FR Jr, Michelis MF, Bloom ME, et al. Impaired water excretion in
myxedema. Am J Med 1971;51:41–53.
29. Hanna FW, Scanlon MF. Hyponatraemia, hypothyroidism, and role of arginine-
vasopressin. Lancet 1997;350:755–6.
30. Swanson JW, Kelly JJ Jr, McConahey WM. Neurological aspects of thyroid
dysfunction. Mayo Clin Proc 1981;56:504–12.
31. Garber J, Cobin R, Gharib H, et al. Clinical practice guidelines for hypothyroidism
in adults: cosponsored by the American Association of Clinical Endocrinologists
and the American Thyroid Association. Thyroid 2012;22(12):1200–35.
32. Gharib H, Cobin R, Dickey R. Subclinical hypothyroidism during pregnancy:
position statement from the American Association of Clinical Endocrinologists.
Endocr Pract 1999;5(6):367–8.
33. Wall CR. Myxedema coma: diagnosis and treatment. Am Fam Physician 2000;
62(11):2485–90.
34. Davis PJ, Davis FB. Hypothyroidism in the elderly. Compr Ther 1984;10:17–23.
35. Bailes BK. Hypothyroidism in elderly patients. AORN J 1999;69:1026–30.
36. Schenck JB, Rizvi AA, Lin T. Severe primary hypothyroidism manifesting with
torsades de pointes. Am J Med Sci 2006;331:154–6.
37. Fukunaga K. Refractory gastrointestinal bleeding treated with thyroid hormone
replacement. J Clin Gastroenterol 2001;33:145–7.
38. Klubo-Gwiezdzinska J, Wartofsky L. Thyroid emergencies. Med Clin North Am
2012;96(2):385–403.
39. Arlot S, Debussche X, Lalau JD, et al. Myxoedema coma: response of thyroid hor-
mones with oral and intravenous high-dose L-thyroxine treatment. Intensive Care
Med 1991;17:16–8.
40. Mandel S, Brent G, Larsen PR. Levothyroxine therapy in patients with thyroid
disease. Ann Intern Med 1993;119:492–502.
41. YamamotoT, FukuyamaJ, Fujiyoshi A. Factorsassociatedwithmortalityof myxedema
coma: report of eight cases and literature survey. Thyroid 1999;9(12):1167–74.
42. Mathew V, Misgar RA, Ghosh S, et al. Myxedema coma: a new look into an old
crisis. J Thyroid Res 2011;2011:493462.
43. Kearney T, Dang C. Diabetic and endocrine emergencies. Postgrad Med J 2007;
83:79–86.
44. Dutta P, Bhansali A, Masoodi SR, et al. Predictors of outcome in myxedema
coma: a study from a tertiary care centre. Crit Care 2008;12:R1.
Hypothyroidism 317